Meeting NewsPerspective

STEMI Accelerator-2: Coordinated emergency systems of care reduce treatment times, mortality

ANAHEIM, Calif. — The addition of full-time regional coordinators and mentors to help organize care among emergency services and primary PCI hospitals reduced time to reperfusion and mortality among patients with STEMI, researchers reported at the American Heart Association Scientific Sessions.

In the United States, fragmented delivery of emergency cardiac care impacts effective and life-saving treatment for patients with acute MI, according to James G. Jollis, MD, from the Duke Clinical Research Institute and the University of North Carolina at Chapel Hill.

“For patients with MI due to an abruptly closed artery, the national standard involves paramedics diagnosing with an ECG and calling in the catheterization team prior to hospital arrival so patients are treated quickly before complications and severe heart muscle damage ensue,” Jollis said during a press conference.

For the Mission: Lifeline Accelerator-2 project, led by the AHA and Duke Clinical Research Institute, Jollis and colleagues built on lessons learned from the Accelerator-1 project. The investigators sought to improve coordination among emergency services and primary PCI hospitals by implementing regional plans that included a full-time regional coordinator and expert mentors who worked with local leaders, health care professionals, paramedics, nurses, emergency physicians and cardiologists to establish common protocols and implement data measurement and feedback.

Improved treatment times, outcomes

The STEMI Accelerator-2 study involved 21,160 patients with STEMI presenting to 132 hospitals with 971 EMS agencies in 12 major U.S. metropolitan regions. A total of 10,730 patients transported by paramedics from April 2015 to March 2017 were included in the analysis. Data were collected in the ACTION–Get With the Guidelines Registry for quarterly reports.

The primary endpoint was change in the proportion of patients transported by EMS with first-medical-contact-to-device time of 90 minutes or less from baseline to the final quarter. Treatment times and mortality were also compared with patients treated in hospitals that were not participating in Accelerator-2 during the same time period.

From the baseline quarter to the final quarter, the proportion of patients with a first-medical-contact-to-device time of 90 minutes or less improved from 67% to 74% (P < .002). Additionally, more patients achieved a first-medical-contact-to-cath-lab time of less than 20 minutes (38% to 56%; P < .0001). Results also showed an increase in the proportion of patients with an ED dwell time of less than 20 minutes (33% to 43%; P < .0001) in the final quarter.

In terms of outcomes, improvements in treatment times were associated with a significant reduction from baseline to the final quarter in in-hospital death (4.4% to 2.3%; P = .008) and congestive HF (7.4% to 5%; P = .03). Notably, the reduction in in-hospital death was not seen in programs that did not participate in Accelerator-2.

B. Hadley Wilson

Among the 12 regions, nine reduced first-medical-contact-to-device time and eight met or exceeded the national goal of 75% of patients treated in less than 90 minutes.

The data were simultaneously published in Circulation.

Benefits of organized systems of care

These results, Jollis noted, demonstrate the effectiveness of regional care coordinators and implementing organized systems of care so that paramedics can diagnose MI and activate cath lab teams more quickly, which translates to better treatment times and decreased mortality.

“This is the first large-scale study that has been conducted in large populations showing that our efforts to incorporate ways to speed patients with MI to hospitals work and save lives,” B. Hadley Wilson, MD,  secretary and chair of the Board of Governors with the American College of Cardiology and interventional cardiologist at Carolinas HealthCare System’s Sanger Heart & Vascular Institute, who also worked on the STEMI Accelerator-2 project, told Cardiology Today’s Intervention. “These data are going to strengthen the guidelines, nationally and internationally, for heart attack care.” – by Melissa Foster

References:

Jollis JG. LBS.06 - Evaluating Quality Improvement and Patient-Centered Care Interventions. Presented at: American Heart Association Scientific Sessions; Nov. 11-15, 2017; Anaheim, California.

Jollis JG, et al. Circulation. 2017;doi:10.1161/CIRCULATIONAHA.117.032446.

Disclosures: The study was sponsored by research and educational grants from AstraZeneca and The Medicines Company. Jollis and Wilson report no relevant financial disclosures.

ANAHEIM, Calif. — The addition of full-time regional coordinators and mentors to help organize care among emergency services and primary PCI hospitals reduced time to reperfusion and mortality among patients with STEMI, researchers reported at the American Heart Association Scientific Sessions.

In the United States, fragmented delivery of emergency cardiac care impacts effective and life-saving treatment for patients with acute MI, according to James G. Jollis, MD, from the Duke Clinical Research Institute and the University of North Carolina at Chapel Hill.

“For patients with MI due to an abruptly closed artery, the national standard involves paramedics diagnosing with an ECG and calling in the catheterization team prior to hospital arrival so patients are treated quickly before complications and severe heart muscle damage ensue,” Jollis said during a press conference.

For the Mission: Lifeline Accelerator-2 project, led by the AHA and Duke Clinical Research Institute, Jollis and colleagues built on lessons learned from the Accelerator-1 project. The investigators sought to improve coordination among emergency services and primary PCI hospitals by implementing regional plans that included a full-time regional coordinator and expert mentors who worked with local leaders, health care professionals, paramedics, nurses, emergency physicians and cardiologists to establish common protocols and implement data measurement and feedback.

Improved treatment times, outcomes

The STEMI Accelerator-2 study involved 21,160 patients with STEMI presenting to 132 hospitals with 971 EMS agencies in 12 major U.S. metropolitan regions. A total of 10,730 patients transported by paramedics from April 2015 to March 2017 were included in the analysis. Data were collected in the ACTION–Get With the Guidelines Registry for quarterly reports.

The primary endpoint was change in the proportion of patients transported by EMS with first-medical-contact-to-device time of 90 minutes or less from baseline to the final quarter. Treatment times and mortality were also compared with patients treated in hospitals that were not participating in Accelerator-2 during the same time period.

From the baseline quarter to the final quarter, the proportion of patients with a first-medical-contact-to-device time of 90 minutes or less improved from 67% to 74% (P < .002). Additionally, more patients achieved a first-medical-contact-to-cath-lab time of less than 20 minutes (38% to 56%; P < .0001). Results also showed an increase in the proportion of patients with an ED dwell time of less than 20 minutes (33% to 43%; P < .0001) in the final quarter.

In terms of outcomes, improvements in treatment times were associated with a significant reduction from baseline to the final quarter in in-hospital death (4.4% to 2.3%; P = .008) and congestive HF (7.4% to 5%; P = .03). Notably, the reduction in in-hospital death was not seen in programs that did not participate in Accelerator-2.

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B. Hadley Wilson

Among the 12 regions, nine reduced first-medical-contact-to-device time and eight met or exceeded the national goal of 75% of patients treated in less than 90 minutes.

The data were simultaneously published in Circulation.

Benefits of organized systems of care

These results, Jollis noted, demonstrate the effectiveness of regional care coordinators and implementing organized systems of care so that paramedics can diagnose MI and activate cath lab teams more quickly, which translates to better treatment times and decreased mortality.

“This is the first large-scale study that has been conducted in large populations showing that our efforts to incorporate ways to speed patients with MI to hospitals work and save lives,” B. Hadley Wilson, MD,  secretary and chair of the Board of Governors with the American College of Cardiology and interventional cardiologist at Carolinas HealthCare System’s Sanger Heart & Vascular Institute, who also worked on the STEMI Accelerator-2 project, told Cardiology Today’s Intervention. “These data are going to strengthen the guidelines, nationally and internationally, for heart attack care.” – by Melissa Foster

References:

Jollis JG. LBS.06 - Evaluating Quality Improvement and Patient-Centered Care Interventions. Presented at: American Heart Association Scientific Sessions; Nov. 11-15, 2017; Anaheim, California.

Jollis JG, et al. Circulation. 2017;doi:10.1161/CIRCULATIONAHA.117.032446.

Disclosures: The study was sponsored by research and educational grants from AstraZeneca and The Medicines Company. Jollis and Wilson report no relevant financial disclosures.

    Perspective
    Gregg C. Fonarow, MD

    Gregg C. Fonarow

    With STEMI, every minute counts. Ideally, in the field, first responders would take patients to fully PCI-capable hospitals where the team has been pre-activated and they are quickly transported to the cath lab.

    The STEMI Accelerator-2 data are incredibly impressive because, overall, the intervention has led to faster treatment times that have translated to a decline in in-hospital mortality that was not seen to the same degree in regions not targeted for the Accelerator-2 program. The intervention has yielded impressive results that can hopefully be scaled up.

    The study has a few potential limitations. For instance, there was not randomization and there may be important differences that account for trends over time. We also saw that although nine hospitals improved, three did not. It is critically important to understand what were the best practices in those hospitals that responded, what were the remaining barriers and how we can overcome those barriers.

    Now that we are seeing improvements in treatment times with Accelerator-2, we must think how we can marshal resources so that any individual having an MI is going to have the fastest time to treatment and the best clinical outcomes, how we can implement these changes on a national level, and how we can have even more rapid treatment times that may translate into further reductions in mortality and adverse outcomes.

    • Gregg C. Fonarow, MD
    • Director, Ahmanson-UCLA Cardiomyopathy Center
      Co-Director, UCLA Preventative Cardiology Program
      Co-Chief, UCLA Division of Cardiology
      Eliot Corday Chair in Cardiovascular Medicine and Science

    Disclosures: Cardiology Today could not confirm relevant financial disclosures.

    Perspective

    This is a nice study that is an extension of work that was done earlier under the Mission: Lifeline initiative. The earlier work showed that improvements in processes of care around patients with STEMI could be made if a package of best-care plans were brought forward to individual hospitals and practitioners. However, the earlier work was not as successful as expected in terms of moving the needle on patient care.

    As a result, the researchers and those behind that earlier initiative looked at the work that had been done, tried to identify where barriers existed to improvements and process, and then focused on overcoming those barriers. It appears that they focused on a couple of key barriers. One potentially very important area was the identification of a dedicated coordinator who would be assigned to a region and would then coordinate activities at the various participating hospitals. One question I have for the authors pertains to the specific work of the coordinator. The manuscript provides some information, but not much detail about how that person operated. Nevertheless, it does seem that the presence of that regional coordinator was a key difference between the earlier and later experiences for Mission: Lifeline.

    In this newer study, significant improvements were made in process measures, including first-medical-contact-to-intervention time and dwell time in the ED. Importantly, although it was not a primary objective of the study, there was improvement in in-hospital mortality, which was not observed in hospitals that did not participate in this second phase of the Accelerator program. This is good evidence showing that these process improvements impacted clinical outcomes.

    The main takeaway point from this study is that systematic approaches to improving care processes work. Patients with STEMI are obviously a high-risk population for whom we know delays in treatment carry clinical consequences. Therefore, any standardized care plan that we can put in place that helps reduce variability in care and delays in care should provide clinical benefit. This is one more important study that aims us in that direction.

    • Kirk N. Garratt, MD, MSc
    • President, Society for Cardiovascular Angiography and Interventions
      John H. Ammon Chair, Cardiology
      Associate Director, Center for Heart and Vascular Health
      Christiana Care Health System
      Newark, Delaware

    Disclosures: Garratt reports he was a participant in the first ACTION–Get With the Guideline Mission: Lifeline initiative. He is also the chair for the ACTION–Get With the Guidelines Research and Publication Committee and reviews materials being produced through the Mission: Lifeline initiative, but he is not a participant or author for this study. He reports no relevant financial disclosures.

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